Antepartum Fetal Testing

Antepartum Fetal Testing: Examining the Evidence
Presentation lecture by:Jay J Bringman, MD
University of Tennessee Health Sciences Center, Memphis

Objectives
* Understand physiology behind antepartum fetal testing
* Review evidence for antepartum fetal testing
* Indications for testing
* Review what test to use
* What to do with an abnormal test
* When to start and the frequency in which to test

Cerebral Palsy
* Case-control study of term infants weighing >2500g in Australia
* Case: neonate with diagnosed moderate or severe neonatal encephalopathy in first week of life
* Control: term neonate without diagnosis of neonatal encephalopathy
* Evaluated role of preconceptional, antepartum and intrapartum factors in neonatal encephalopathy
* Strongest antepartum risk factor for NE is IUGR; OR 38.2 (9.4-154.8)
* Other risk factors:

Physiologic basis for antenatal testing
* Fetal testing designed to assess for fetal hypoxia

Non-stress test physiology
* Afferent signals:
* When stimulated, send afferent impulses to brain to increase FHR
* Efferent signals increase FHR
* If movement and accelerations observed, reasonable to conclude the afferent and efferent limbs intact and cardioregulatory neurons adequately oxygenated

NST: How to do it
* Patient in lateral tilt position
* Tracing observed for 40 minutes
* Accelerations peak (but do not necessarily remain) at least 15 BPM above baseline
* Last for 15 seconds
* Reactive: 2 or more accelerations within 20 m period
* Nonreactive: one that lacks sufficient accelerations over 40 minute period
* No contraindications

The preterm fetus
* Frequently nonreactive
Evidence for use of NST
Randomized trials
Caveats
NST versus VAS
NST and nonrandomized data
Caveat for observational data
Contraction stress test
CST interpretation
Biophysical profile
What score tells you…

* Normal acute variables and AFI
* Normal pH and blood gases secondary to compensation
* Abnormal blood gases and normal AFI
* Abnormal acute and abnormal blood gases
* Goal is to recognize asphyxia and deliver prior to morbidity and mortality

Cesarean delivery
IOL for abnormal testing
Induction of labor
Nonrandomized data
Biophysical profile
Fetal movement assessment
Indications for antepartum monitoring
Maternal and Fetal Indications
Which test to use?
* Most evidence points to use of NST as first line test
* Imperative to remember that it should not be used a sole test
* Other tests should be used in situation of nonreassuring testing such as BPP or CST
* NST can be used in conjunction with Doppler studies in IUGR

What to do if test is abnormal?
* True false-positive test results not known
o Test introduced without rigorous evaluation of utility
* Abnormal result in context of clinical situation
o Did maternal condition change?
o Abnormal test usually followed by other test
+ 90% of NRNSTs followed by negative CST
o If NRNST followed by positive CST, delivery warranted in morphologically normal fetus

Abnormal BPP
When to start?
How frequently?

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PREGNANCY 1st and 2nd Trimesters

PREGNANCY 1st and 2nd Trimesters
Presentation lecture from: Orangecoastcollege

* General
o Sonography used after 4-5 weeks
o Events prior to this time:
1. Ovulation
2. Fertilization
3. Implantation
4. Placentation
5. Embryonic Development

OVULATION
A. Definition: a cyclic event controlled by two hormones (FSH and LH) that occurs monthly

1. ~ 20 ova begin maturing
2. Only one completes the maturation process
Phase??
3. After ovulation, ovum moves into uterine tube
4. If fertilized, the zygote begins to divide
5. Implantation begins in ~6 days

FERTILIZATION
A. Definition: penetration of the ovum by one spermatozooan

1. Hyaluronidase (from acrosome):enzyme that allows penetration
2. Lack of acrosome/enzyme: infertility
3. Polyspermy: More than one sperm penetrates ovum

B. Sperm and ovum are haploid (N)
C. Genetic material in nuclei fuses to form zygote (2N)
D. Zygote begins cell division (mitosis!) immediately
E. Differentiation: prior to reaching uterus, zygote has developed into morula
+ Cells continue to divide, form blastula or blastocyst
# trophoblast
# inner cell mass or blastoderm
G. Trophoblast will give rise to placenta
H. Inner cell mass will give rise to the embryo
1. Ectoderm (outer layer or “outer skin”)
2. Endoderm (inner layer or “inner skin”)
3. Mesoderm (middle layer or “middle skin”)


Primary Germ Layers

Implantation
The Uterus
Perimetrium
Myometrium
Endometrium
Placenta & Fetal Membranes
Placental formation
Chorion Frondosum
Formation of Umbilical Vessels
Fetal membranes
Umbilical Cord
Anomalies
Meckel’s Diverticulum
May indicate fetal demise, premature rupture of membranes
Omphalocele
Ectopic Pregnancy
Metastatic Carcinomas
Spread via lymph circulation
Rectouterine Pouch (of Douglas) or cul-de-sac
Hydrocephaly
Hydrocephalus
Anencephaly:
Porencephaly
Doppler U/S of the Circle of Willis in utero
Circle of Willis
Fetal circle of Willis: 3D U/S
Ultrasound-guided Prenatal Diagnosis
Amniocentesis and CVS
Pelvic masses
Uterine Anomalies
Uterus bicornis
Uterus didelphys
Uterus unicornis

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High Risk Pregnancy

High Risk Pregnancy
Presentation By:Susan Sienkiewicz

Adolescent Pregnancy: Contributing Factors
Implications of Adolescent Pregnancy
Socioeconomic:
* reliance on welfare
* cycle repeats itself

Maternal health:
* CPD
* PIH
* anemia
* nut deficits
* mortality

Fetal Health:
* LBW
* prematurity
* resp complications
* cp
* cognitive deficits
* death

Adolescent Pregnancy: Assessment
* Risks
* fundal height
* # of sexual partners
* knowledge of infant care/needs
* family unit/support system
* baseline VS/weight

IMPLICATIONS OF DELAYED PREGNANCY
* Pre-existing conditions
* Preterm labor SGA/LBW
* IUGR
* PIH Abruption
* C-section
* Uterine fibroids PP hemorrhage
* Chromosomal abnormalities


DELAYED PREGNANCY: ASSESSMENT
* Pre-existing conditions
* Fundal height
* Anxiety
* Psychosocial issues

TYPES OF SPONTANEOUS ABORTIONS
Spontaneous Abortion Management
Threatened
Inevitable
Incomplete
Missed
Post Abortion Education
SITES OF ECTOPIC PREGNANCY
S & S Ectopic Pregnancy
Surgical Management of Ectopic Pregnancy
Med Mgmt of Ectopic PG
MTX
S & S Hydatiform Mole
Therap. Mgmt: vacuum aspiration & curettage
Spontaneous Abortion Matching – Choose all that apply.
Medical Mgmt of Placenta Previa
Mom stable,fetus immature
Fetus > 36 wks
S&S Abruptio Placentae
Med Mgmt of Placental Abruption
Placental Bleeding
Thromboplastin release
Clot formation (systemic response)
clotting factors (fibrinogen, plts, PTT, FDP)
inability to form clots
profuse bleeding
Hemorrhagic Conditions: Abruption & DIC
ASSESSMENT
The Pathological Processes of Pre-eclampsia
S&S Pre-eclampsia
Treatment of Pre-eclampsia
Mild: diastolic
Severe: diastolic
S&S Eclampsia/HELLP Syndrome
* Eclampsia
* HELLP Syndrome
Treatment of Eclampsia/HELLP Syndrome
* Bedrest
* Meds
* Delivery
Assessment: Hypertensive Disorders of Pregnancy
Risk Control Strategies for Hypertensive Disorders of Pregnancy
Incompetent Cervix
Treatment
Premature Labor/Rupture of Membranes
Nursing Care for PTL/PROM
Postterm Pregnancy
Disorders of Amniotic Fluid
Risks of Multifetal Gestation
(Fetal) S&S Rh Incompatibility
Sequence of Assessments for Rh Sensitization
Blood Test for Type & Rh Factor
Management of Rh Incompatibility
Prenatal
Hyperemesis Gravidarum
Glucose Tolerance Test
Gestational Diabetes is diagnosed with FBS > 105 or with 2 of the following BS results:
Effects of Pre-Existing DM
* Maternal
* Fetal
Treatment of Pre-existing DM
Effects of Gestational Diabetes
Diabetes: Patient Education
PPCM: Manifestations
PPCM: Energy Management
PPCM: Cardiac Care
PPCM: Patient Education
Sickle Cell Disease
Systemic Lupus Erythematosis
AIDS
Treatment:
CASE STUDY

High Risk Pregnancy.ppt

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